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Lipedema is a condition in which fat cells enlarge in the legs and occasionally the arms. This usually happens symmetrically and affects both legs, starting at the hips and slowly progressing down to the ankle over years. It is generally an inherited disorder that affects almost exclusively women and is felt to have a hormonal component.
With lipedema, the legs can appear “swollen” and this can be confused with lymphedema. Lipedema doesn’t involve the top of the feet, but lymphedema does. Lipedema affects almost exclusively females, and it is estimated that 10% of women have this condition in some form.
Lipedema is felt to have a hormonal relationship. The fat cells are different from the fat cells in the trunk of the body and they are very resistant to diet and exercise. After years of the condition, it can affect the lymphatics of the leg with resultant lymphedema and swelling of the feet.
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The earliest signs are generally the development of “saddlebags” on the hips in adolescence, the early 20s or during pregnancy. This fatty enlargement then begins its progression toward the feet, causing dimpling of the thighs. Although enlargement is circumferential, eccentric deposits may be found in the lower, inner thighs and upper-inner calves. This is usually symmetrical between the legs, but one side may develop faster.
Often, patients’ chief complaint is of swelling and enlargement of tissue around the ankle. On careful questioning, the “swelling” may not change much as the day progresses, and it may not subside overnight. Ultrasound evaluation at the ankle later in the day will not show fluid in the tissue. Unfortunately, if there is coexisting vein and/or lymphatic disease, there can be swelling with the finding of fluid in the tissue.
Lipedema by itself can create column-like ankles. Sometimes the fatty tissue of the legs is tender and patients may complain of easy bruising. History reveals poor-to-no results with diet and exercise from the hips down, although the upper body responds.
Vein disease in no way contributes to the development or progression of lipedema, but lipedema can exacerbate vein disease and the combination of the two can predispose patients to lymphedema. Venous insufficiency in association with lipedema should be treated to avoid swelling and decrease the chances of lymphedema.
Early stages of lipedema can be conservatively treated with use of compression bike shorts or capris. In more advanced stages, complete decongestive therapy (CDT), including manual lymphatic drainage with compression therapy, is beneficial. Keep in mind that the reduction that is typically seen in lymphedema patients will not be as pronounced in lipedema patients due to the abnormal deposits of adipose tissue. CDT will affect the excess fluid in the tissue space and will slow the progression of this condition.
Beyond conservative therapy, lymph-sparing water-assisted liposuction (WAL) can gently give localized control of fatty enlargement with repeated procedures. More aggressive therapy risks lymphatic disruption and fluid buildup.
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